P1666: THE BURDEN OF VENOUS THROMBOEMBOLISM AND THE CHALLENGES IN DELIVERING ADEQUATE CARE IN THE SETTING OF POVERTY, HOMELESSNESS, AND SOCIAL EXCLUSION: A SINGLE CENTRE CROSS-SECTIONAL STUDY
Authors: Ellen O’rourke, Chloe Carpenter, Shane Toolan, Lidhy Solomon, Fionnuala Ní Ainle, Barry Kevane
Journal: HemaSphere (2023)

Topic: 34. Thrombosis and vascular biology - Biology & Translational Research Background: Social exclusion is a multi-dimensional state characterised by the inability of an individual to participate in the normal social, economic and cultural activities of society. It arises as a result of an interplay between adverse biological, social & psychological factors including poverty, social deprivation and ill-health. Social exclusion is frequently experienced by homeless people, people with substance misuse disorders and other marginalised populations including prisoners, sex workers and people with severe & enduring mental illness. Socially excluded persons (SEP) frequently encounter challenges in accessing healthcare services and exhibit earlier onset of disease and higher mortality rates than the general population. VTE is a leading cause of morbidity and mortality globally. Low socio-economic status is associated with an increased risk of VTE. Among the SEP population, VTE risk is particularly increased among those who engage in injecting drug mis-use (IVDU; injecting of heroin or other drugs into the proximal lower limb veins). In Ireland, social exclusion & homelessness are associated with high rates of IVDU. Aims: The Mater Misericordiae University Hospital is a large teaching hospital serving a diverse urban population in inner-city Dublin. In this study we aimed to determine the proportion of new VTE referrals to the thrombosis clinic which related to SEP and to identify the challenges faced by this vulnerable population. Methods: A cross-sectional study was undertaken where health records pertaining to all individuals referred to a specialist thrombosis clinic with acute VTE during the 12-month period from June 2021-May 2022 were assessed. Clinical/demographic data were extracted and the characteristics of individuals who met criteria for social exclusion (current or prior IVDU; methadone use; hepatitis C; homelessness; incarceration; or severe/enduring mental illness) were compared to the general population of VTE patients. Results: During the study period, there were 170 new VTE referrals of which 35 (21%) related to SEPs. Within the SEP group, 22 (62.9%) reported active/prior IVDU and 19 (54.3%) were homeless. 13 (37.1%) had a concurrent diagnosis of a major mental illness and 16 (45.7%) had a history of hepatitis C and/or HIV. In comparison to the general VTE population, SEP were significantly younger at the time of referral [median age 46 (IQR 42-55) vs 62 (IQR 47-72) years; p<0.001] and a higher proportion had a history of prior VTE (57.1% vs 23.7%; p=<0.001). The majority of SEP with prior VTE had a history of active/prior IVDU (16/20; 80%). The rate of non-attendance for clinic review was higher in the SEP group (57.1% vs 20%; p<0.0001) and current treatment status was unknown in 25.7% of the SEP group in contrast to 8.1% in the general population (p=0.02). The rate of re-attendance at the emergency department following VTE diagnosis was significantly higher in the SEP population (42.9% vs 12.6%; p=<0.001). Summary/Conclusion: SEPs make up a substantial proportion of patients with acute VTE presenting to our institution. These vulnerable patients present with complex care needs and co-morbidities including high rates of recurrent VTE, psychiatric illness and homelessness. Delivering adequate VTE treatment is challenging, as evidenced by the high rates of non-attendance, loss to follow-up, re-attendance for unscheduled emergency care and recurrent VTE among this population. Novel approaches to the delivery of care are urgently required in order to mitigate the potential risk of mortality and chronic morbidity associated with VTE in this population. Keywords: Coagulation, Thrombosis, Venous thrombosis, Venous thromboembolism